Encouraging patients to live well with diabetes

24 November 2021

World Diabetes Day was Sunday 14 November 2021, focusing on the importance of improving access to diabetes care for all and the need for action to prevent diabetes and its complications.

Kiama Downs Medical Practice took part in COORDINARE’s Resilience in General Practice initiative, providing an opportunity to strengthen their resilience by implementing models of care that are focused on patients most at risk of poor health outcomes in the context of COVID-19.

We spoke with Practice Nurse Fran Day, Dr Tom HIlliar and the team at Kiama Downs Medical Practice about their Diabetes Resilience Project and how they helped patients better manage their diabetes with early intervention, ongoing support and management. 


Q. How and why did the Resilience Project come about at Kiama Downs Medical Practice?

A. Diabetes is the fastest growing chronic condition in Australia with more than 120 Australians developing diabetes in the past year. The Diabetes Resilience Project came about because we were aware that many of our patients with diabetes had been isolating at home and not attending regular reviews with their GPs, and not accessing pathology due to their vulnerability to COVID-19. We wanted to be proactive and engage with our patients to prevent deterioration in their condition.

After reviewing our patient database, we identified 176 patients with diabetes, 89 (50%) of these patients were likely to benefit from the project as they either had no HbA1C or a HbA1C > 8%. We also identified 75 patients (43%) who meet the high-risk criteria of a HbA1c > 8% with cardiovascular disease and/or renal impairment GFR < 60 and/or a current smoker.


Q. What steps are involved in your interaction with patients and what improvements did you hope to see? What improvement have you seen?

A. The project involved a nurse-led clinic which aimed to improve the care provided to patients with diabetes and facilitate more frequent reviews and discussions between the GP and patient. The project also aimed to provide care in a culturally sensitive way. Our patients who met the criteria were contacted and invited to join the project. Those patients that agreed met with myself (Fran) for 30 minutes and GP Dr Tom Hilliar for 15 minutes during the initial consultation. Our goal was to see an improvement in HbA1c in the target population, improvement in healthy lifestyle (smoking and alcohol), improvement in foot care (foot exam completed within 6 months), and improvement in vision screening (optometry attended within 12 months).

Our model of care was very much patient-focused and flexible as we wanted our patients to set realistic and achievable goals. We have seen improvements in healthy lifestyle, an increase in exercise, and have noticed a greater uptake of allied health including podiatry and optometry. We have also been able to identify early those patients who would benefit from referral back to endocrinology for their diabetes management.


Q. How have you managed diabetes management in the context of COVID-19?

A. The main aim was to encourage our patients to live well with diabetes. We wanted to prevent their diabetes from worsening during the pandemic - we achieved this through working with the patient to set goals and help them overcome barriers they faced during the pandemic, and especially during the lockdown period.

COVID-19 has created many barriers to living well with diabetes – such as contributing to a more sedentary lifestyle, perhaps eating more unhealthy foods and not attending regular appointments to access specialists, optometry and podiatry. In addition, our patients’ mental health has been greatly impacted by COVID-19 and we have been able to provide that additional time to each individual and offer support. We have encouraged patients not to put their diabetes management on hold just because of COVID-19. We offered advice on maintaining a healthy weight, encouraging regular physical activity, making healthy food choices, managing blood pressure, cholesterol levels and smoking cessation.


Q. Did you see challenges/exacerbations during the COVID-19 lockdown and how did you manage that?

A. Unfortunately, we met some challenges when we went back into lockdown in August and found some patients were understandably reluctant to attend the practice in person. In order to keep our patients involved and engaged in the project we contacted them via phone to check in. More recently, the majority of participants have then been able to attend the practice for follow-up. We want the momentum of this project to continue long after the project is complete, so we have also utilised Best Practice to set reminders for our patients to attend their regular diabetes review with their nurse and GP.


Q. What have been some good outcomes for patients diagnosed with diabetes?

A. We’ve seen several positive outcomes for patients who participated in the project. These range from simple prompts for patients to attend specialist appointments which has led to a positive change in their diabetes management, to making small lifestyle and dietary changes leading to improvement in Hba1c, but most importantly patient confidence in their ability to manage their diabetes.
We’ve had a very successful outcome for one patient, in particular, who has been very grateful for the extra support over the past year. This gentleman went from being reluctant to make any changes even though his diabetes was poorly managed, to embracing the need to change the management of his diabetes and transition to insulin. It has been a pleasure to support him on his journey and has personally made the project worthwhile for me.


Q. What advice would you give to patients who haven’t attended their general practice for a recent review?

A. Don't delay! Diabetes requires daily self-care and if complications develop, diabetes can lead to serious medical complications and have a significant impact on quality of life. Your GP and nurse teams are there to offer you support and help you manage your diabetes.


Q. What would you say to any general practices thinking of introducing a similar initiative?

A. The Diabetes Resilience Project has been very timely given the current pandemic. It has provided us with the time to offer that additional support to our patients and has been a success. The key is to set realistic outcomes and allocate a lead person to execute your project/initiative.


You can find out more information on the Resilience in General Practice initiative here.

COORDINARE has a range of resources to support your practice in implementing quality improvement activities like this. For help with any quality improvement projects please contact your Health Coordination Consultant or email info@coordinare.org.au.

Chronic conditions, COORDINARE news, Illawarra Shoalhaven, Integrated care, Learning and workforce development, Quality in general practice